The Oaks at Belmont: Pressure Wound Care Failures - MI
The resident, identified in inspection records as Resident 104, had a documented history of pressure ulcers on her left lower buttocks and an unstageable pressure wound on her left heel. Both buttocks wounds had been recorded as resolved in May. The heel wound history remained in her record. She was supposed to receive Triad cream, a topical medication, applied to her buttocks twice daily by nursing staff.
When the facility's Assistant Director of Nursing, identified in the report as ADON C, went to locate the cream during the inspection, it was gone. Not misplaced somewhere in the room. Not sitting on a shelf nearby. It was not in her room and it was not in the medication cart. ADON C confirmed both.
That was not the only gap inspectors found.
The facility had put a new skin monitoring process in place after a separate pressure ulcer finding involving another resident, Resident 101. Under that process, CNAs were required to document any skin concerns on a skin observation form and submit it to the nurse and to the Director of Nursing. It was the facility's own response to its own prior failure.
Resident 104 had zero skin observation forms on record.
Not one had been completed or submitted for her at the time of the inspection.
ADON C also told inspectors that staff providing direct care and linen changes for Resident 104 were required to wear gloves and a gown. The inspection report does not document whether that protective equipment requirement was being followed consistently, but the missing cream and the absent documentation were enough to constitute a finding of actual harm.
Pressure wounds are graded by severity, and unstageable wounds, like the one documented on Resident 104's heel, carry particular risk. An unstageable wound is one where the wound base cannot be fully assessed because it is covered by dead tissue, either slough, which appears soft and yellow or white, or eschar, which is black, brown, or tan. Both types of tissue block healing and require removal before a wound can close. Inspectors included a reference to a standard nursing textbook in their findings to underscore what proper wound assessment requires: evaluating the type and percentage of tissue in the wound bed, the color and odor of any drainage, pain levels, and the condition of the skin surrounding the wound.
Excessive drainage signals infection. Redness, warmth, or firmness in the surrounding skin signals deterioration. These are not subtle findings. They are the basics of wound monitoring, the things a care team is supposed to catch when they are paying attention and documenting what they see.
The inspection was triggered by a complaint. It covered a small number of residents and resulted in a finding of actual harm. The Oaks at Belmont had already been through one pressure ulcer investigation involving a different resident before this inspection took place. The skin observation form process, the one that produced no paperwork for Resident 104, was the facility's own corrective measure from that earlier finding.
Whether Resident 104's wounds worsened during the period when her cream was missing and her skin was going unmonitored, the inspection report does not say. What it says is that the cream was gone, the forms were never filed, and the process the facility created to prevent exactly this kind of gap had not been applied to her at all.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Oaks At Belmont from 2025-08-11 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 3, 2026 · Our methodology
The Oaks at Belmont in Belmont, MI was cited for violations during a health inspection on August 11, 2025.
Both buttocks wounds had been recorded as resolved in May.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.